NCLEX Pre OP Care Q AND A COMPLETED TO PASS

NCLEX Pre OP Care Q AND A COMPLETED TO PASSThe nurse monitors a postoperative client for signs of complications. Which signs/symptoms should the nurse determine to be indicative of a potential complication? Increasing restlessness The nurse is reinforcing instructions to a client and family regarding home care following cataract removal from the left eye. The nurse should provide the client with which instruction regarding positioning in the postoperative period? Do not sleep on the left side. The nurse is caring for a client following a total abdominal hysterectomy. The nurse anticipates that which postoperative outcome will be the priority in the first 24 hours following surgery? Pain The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which nursing action should be performed? Continue to monitor the vital signs. When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should plan to do which action in the initial care of this wound? Apply a sterile dressing soaked with normal saline. The nurse receives a client in the surgical unit who was transferred from the postanesthesia care unit. The nurse checks the client for what data first? A patent airway The student nurse is changing an abdominal dressing on a client with an open incision and notes the presence of sanguineous drainage. Which nursing action would be appropriate? Notify the registered nurse. The nurse is assisting in caring for a client in transfer from the postanesthesia care unit following nasal surgery. Nasal packing and a mustache dressing are in place. The nurse places the client in which position to best reduce swelling? Semi-Fowler's The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation? A urinary output of 20 mL/hour Which nursing action would avoid pressure on the popliteal nerve when applying the safety strap across the client's legs on the operating table? Apply the safety strap 2 inches above the knees. A client who had knee surgery 4 days ago reports to the home health nurse that he has not had a bowel movement since before the surgery. Which question would assist the nurse in the collection of data regarding the client's problem? "What have you been eating and drinking since the surgery?" A client is admitted to the surgical unit postoperatively with a wound drain in place. Which nursing action should the nurse avoid in the care of the drain? Curl the drain tightly and tape it firmly to the body. The nurse monitors the postoperative client frequently, knowing that accumulated secretions can lead to which problem? Pneumonia The nurse is explaining The Joint Commission's (TJC's) universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves which action? The surgeon marking the area of the operative procedure The nurse is caring for a postoperative client who has a drain inserted into the surgical wound. Which action should the nurse avoid in the care of the drain? Secure the drain by curling or folding it and taping it firmly to the body. The nurse in the health care provider's office is measuring vital signs on a postoperative client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. Which statement is appropriate for the nurse to tell the client? "These sensations dissipate over several months and usually resolve after 1 year." The nurse administers scopolamine as prescribed to a client in preparation for surgery. The nurse monitors the client for side effects related to the administration of this medication. Which should the nurse determine is an expected side effect of this medication? Client complaints of a dry mouth